Analysis of Adult Inpatient Malnutrition at the University of Virginia Health System

Abstract

The purpose of this study is to determine the effectiveness of the recent intervention on documentation of malnutrition, and, secondarily, to describe some characteristics of the patients identified as malnourished. Correct documentation and coding of malnutrition relies heavily on communication between registered dietitian nutritionists (RDN) and licensed independent practitioners (LIP). Oftentimes, the malnutrition diagnosis is not documented using the correct terminology for coding, is not documented at all by the LIP, and/or does not include adequate supporting evidence of malnutrition or a nutrition treatment plan. In hospitalized patients, malnutrition is associated with poor outcomes such as readmissions, increased length of stay (LOS), nosocomial infections, and increased healthcare costs. It is important to identify and address inpatient malnutrition in order to provide the best possible outcomes. Hospital reimbursement from the Centers for Medicare and Medicaid Services (CMS) for the treatment of malnourished patients is dependent upon correct documentation and coding, requiring adequate communication among members of the interdisciplinary team. A malnutrition note type in the electronic medical records was introduced in November 2018 to facilitate communication between RDNs and LIPs. Data were collected via Epic reports for adult inpatients admitted January-February of 2018 and 2019. Included in the reports were patients with malnutrition documented on the problem list or malnutrition on the discharge diagnosis. Analysis of variance (ANOVA) and post hoc Tukey test were used to determine significant differences in age and BMI between degrees of malnutrition. Chi square with post hoc analysis was used to determine changes in outcome measures from 2018 to 2019. A total of 724 adult inpatient admissions were analyzed: n(2018)=339, n(2019)=385. Documentation of malnutrition on the problem list increased from 136 to 252 times. There was a significant increase in the number of malnourished patients who were characterized has having malnutrition on admission (p=0.00003). RDN documentation on the problem list increased significantly from 88 times in 2018 to 217 times in 2019 (p=0.001). Service lines with the highest percent of malnourished patients were medical subspecialties and oncology at both time points. Primary discharge diagnosis categories with the highest percent of malnourished patients were oncology, infectious disease, and general medicine at both time points. Implementation of the malnutrition note type resulted in improved documentation of malnutrition at University of Virginia Health System (UVAHS). There were more patients with malnutrition documented on the problem list in 2019, specifically those with moderate and severe malnutrition. Of the patients identified as being malnourished, there was a significant increase in those identified as having malnutrition on admission.